Cefuroxime Activity Against Gonorrhea
Cefuroxime has activity against gonorrhea but should not be used as first-line or even alternative therapy because it fails to meet minimum efficacy criteria and has poor pharmacodynamic properties compared to recommended cephalosporins.
Current FDA-Approved Indication
- Cefuroxime is FDA-approved for treatment of uncomplicated and disseminated gonococcal infections caused by Neisseria gonorrhoeae (both penicillinase- and non-penicillinase-producing strains) 1
Why Cefuroxime Should Not Be Used Despite FDA Approval
Inadequate Efficacy Data
Cefuroxime axetil 1 g orally achieves only 95.9% cure rate (95% CI = 94.5%–97.3%) for urogenital and rectal gonorrhea, which falls below the minimum 95% lower confidence interval threshold required for recommended therapy 2
For pharyngeal gonorrhea, cefuroxime is unacceptable with only 56.9% efficacy (95% CI = 42.2%–70.7%), making it essentially ineffective for this site 2
Poor Pharmacodynamic Profile
Cefuroxime regimens achieve free drug concentrations above the MIC90 for only 6.8-11.2 hours post-dose, compared to 22-50 hours for ceftriaxone or cefixime 3
This borderline pharmacodynamic performance raises serious concern that continued use may select for stepwise increases in resistance, similar to what occurred historically with penicillin 3
Clinical Trial Failures
In a study of pharyngeal gonorrhea, single-dose cefuroxime 1.5 g IM plus probenecid failed in 46% of patients (6 of 13), demonstrating unacceptably poor efficacy at this critical anatomic site 4
While urogenital cure rates of 85.7-98% have been reported in small studies 5, 6, 7, these do not meet the rigorous standards applied to modern gonorrhea therapy
Historical Context
CDC guidelines from 1993 listed cefuroxime axetil 1 g orally as an alternative regimen but noted it had "anti-gonococcal activity and pharmacokinetics less favorable than the 400 mg cefixime regimen" and was "not very effective against pharyngeal infections" 2
By 2006, CDC guidelines acknowledged cefuroxime's suboptimal performance, stating it "does not quite meet the minimum efficacy criteria" 2
Current Recommended Alternatives
Ceftriaxone 250 mg IM plus azithromycin 1 g orally (or doxycycline 100 mg twice daily for 7 days) is the only recommended first-line regimen 2
Cefixime 400 mg orally is no longer first-line due to emerging resistance but remains superior to cefuroxime when ceftriaxone is unavailable, requiring mandatory test-of-cure at 1 week 8, 9
Critical Clinical Pitfall
The most dangerous pitfall is assuming FDA approval equals clinical appropriateness—cefuroxime's FDA indication for gonorrhea predates modern resistance surveillance and efficacy standards, and using it risks treatment failure, particularly for pharyngeal infections, and may accelerate resistance development 2, 3